Accident and Emergency Services (Dementia)
The final item of business is a members' business debate on motion S3M-3215, in the name of Irene Oldfather, on recognising the needs of people with dementia in accident and emergency. The debate will be concluded without any question being put.
Motion debated,
That the Parliament notes the launch of the report, People with Dementia in NHS Accident and Emergency - Recognising Their Needs, by the Cross Party Group on Alzheimer's; is concerned that evidence suggests that, while an estimated 70% of elderly people attending accident and emergency will show some sign of having mental health problems including dementia, less than 10% of problems are identified by admitting doctors; notes evidence that suggests that the average length of stay for an older person with dementia in accident and emergency is between three and seven hours and that readmission for this vulnerable group is likely to result in high levels of functional decline; further notes that mortality rates for patients with dementia admitted to hospital are higher than for other elderly people with some studies suggesting that as many as 30% of such patients die within six months and more than 10% are readmitted and may be placed in institutional care as a consequence; recognises the report's recommendation that where clinically possible there should be a presumption against admission for patients with dementia and that specialist community-based care, including consultant support and diagnostic testing, is desirable; welcomes as a starting point the decision by NHS Ayrshire and Arran to appoint a mental health liaison nurse to lead the development of protocols, policies and guidelines relevant to patients with dementia, and believes that it is important that people with dementia are given appropriate and timely treatment that respects their dignity and independence.
I am grateful to all those across the political parties who signed the motion. I am particularly grateful to the members of the cross-party group on Alzheimer's who worked diligently to prepare the report "People with Dementia in NHS Accident and Emergency—Recognising Their Needs", especially Professor June Andrews, who is in the public gallery; Dr Gillian McLean, from the Royal College of Psychiatrists; and Jan Killeen, from Alzheimer Scotland. As well as those three stars, we have a great group of people on the cross-party group, including people from the Mental Welfare Commission for Scotland and the Scottish Commission for the Regulation of Care, who worked and commented on various drafts, as did my fellow MSPs Mary Scanlon, Richard Simpson, Marilyn Livingstone and James Kelly. I am grateful to the Minister for Public Health and Sport, Shona Robison, for the letter that I have received from her fully endorsing the report and announcing the issuing of draft guidance to health boards. I am sure that she will give more detail on that in her summing up. I will ask for clarification on a few points in a moment.
Part of the cross-party group's remit is to raise awareness of the issue of Alzheimer's, so I want to use the opportunity that the debate provides to demonstrate the challenges that face people with dementia in a hospital environment. I therefore ask members in the chamber to imagine for a moment what it must be like to have Alzheimer's or dementia. If members saw the television programme about Terry Pratchett last week, they will know that dementia can create such a fog of confusion that it can be difficult some days to perform even simple tasks such as tying a tie or making a cup of tea. Dementia is often associated with memory loss, but it can also affect someone's judgment, co-ordination, balance, speech, understanding and moods and their ability to communicate even with those closest to them. Not only can someone present with that complex range of symptoms, their capacity to undertake and understand simple actions can change from day to day.
Can members therefore imagine what it must be like for someone with this multifaceted illness to present at accident and emergency? Even for those who fully understand what is happening, A and E can be a difficult place to be at the best of times. As our report demonstrated, people with dementia can wait for up to seven hours for assessment in A and E. Anyone who has waited for half that time will know how challenging that can be for people with mental incapacity.
The cross-party group's recommendations include using an electronic tag that could flag up to any general practitioner or out-of-hours medical professional that home assessment followed by an appointment, if necessary, would be preferable to a patient being dispatched to sit in A and E, where clinically appropriate. It might be that an X-ray would be required to eliminate the possibility that there has been, say, a wrist fracture. Urgent access to that kind of diagnostic testing by community teams would prevent attendance at A and E, unless treatment was required. However, achieving that will require much better joined-up working in the community. For example, we spoke at the cross-party group about linking to local memory clinics and old age psychiatrists. The minister has addressed that at point 4 of her guidance. I note the associated comment that
"multiple programmes should already be in place to support this."
I would welcome her assurance that she will look closely at implementation to ensure that there is joined-up working across the system, from GPs and NHS 24 to social services and community health teams, where appropriate. Better training, including expanding the range of available options, will result in better outcomes. I welcome the minister's recognition of the importance of that.
With some simple measures, we can save beds and staff time spent trying to handle what can be difficult and challenging situations. Those measures can also save lives because we know that increased mortality rates, higher readmission rates and functional decline are all associated with this vulnerable patient group, who are particularly subject to adverse incidents in hospitals.
For some people, hospital admission will be necessary. The report asks that national health service boards support the Alzheimer Scotland initiative to have a dementia nurse attached to every hospital. At present, Alzheimer Scotland funds three nurses in three board areas. Rather than wait for that initiative to be rolled out, we said in our recommendations that we believe that it is a priority for the initiative to be undertaken across the NHS in Scotland. The minister's guidance notes that dementia-trained nurses are already in the system. I would welcome clarification of whether she supports the principle that each health board should attach a dementia specialist nurse to a hospital to take forward protocols and to support families and carers.
On television a week ago, Terry Pratchett described his feelings on being diagnosed at an early stage with Alzheimer's disease. He said that he felt as though he was standing on a beach—the tide had gone out and there was no one else there. Let us send out a message to people with dementia and their families that no mum or dad, gran or grandpa, neighbour or friend will stand on that beach alone. We in the Scottish Parliament will walk with them on that journey and we will do what we can to make it an easier one. We will change things. Today, in the Scottish Parliament—their Parliament—the tide is turning for them.
I congratulate Irene Oldfather on obtaining this most important debate. I also commend the cross-party group for the sensible suggestions in its Alzheimer's report, which is a classic example of how a cross-party group can advance policy.
I know from my experience as a general practitioner of many years, from helping patients and from members of my own family how easy it is for old people to become destabilised when they are removed from familiar surroundings. Often, one does not realise that an old person has a problem at all while they are in the familiar surroundings of their house, where they know the geography and know where everything is kept. However, the moment that they move to a different situation—to someone else's home or to the strange world of hospital—they can become a different person altogether. That can be not just frightening but even life threatening.
Therefore, although the recommendations in the report concerning the recognition and care of people with dementia in accident and emergency departments are most welcome, the recommendations that are most important to me are those that would help to keep people at home in the first place. Falls should be prevented. It is easy to trip over the edge of a carpet or something that has been left lying around the house. Therefore, every person who is at risk of dementia or Alzheimer's should have their home inspected to make certain that it is easy for them to move from one area to another without tripping over something.
Care in the community is also important. In my early years in general practice, we had a first-rate geriatrician at university, Professor Williamson, who laid down two rules for looking after people, which I felt were extremely important. First, he told carers that, if they rang him with a problem, he would deal with it straight away. That enabled the carers to carry on caring for someone a lot longer than they could have done if they had felt that they would have to join some sort of waiting list. That helped people to stay in their own homes for longer. Secondly, Professor Williamson gave a great deal of respect to the home helps who looked after old people and who he said preceded health services by telling him when people were beginning to change and when things were going wrong. We could give a great deal more respect to the position of home helps in our community and recognise how they can help health in general.
Old people need rapid access to diagnostic testing and the ability to have domiciliary consultations so that, when they become ill, they can be looked after at home. All too often, consultants these days will not go out to someone's house. However, if they go to someone's house, make the correct diagnosis, get the tests done and employ the right treatment, the person can stay at home and not suffer from the problems that we are talking about when they arrive at the accident and emergency or other hospital department.
Finally—and very important, too—there is the issue of the medication that old folk receive in their homes. Too often, one goes to some cabinet, pulls open the door and loads of medicines fall out. The person does not know how the medicines are to be taken, why they are there or what to do with them. Every old person needs a regular medication review at frequent intervals and we need to ensure that they are certain about how to take their medication.
If we put into practice the recommendations in this excellent report, fewer old people will have to go to hospital and fewer people suffering from the effects of dementia will end up in accident and emergency departments.
I call Mary Scanlon, to be followed by Dr Richard Simpson.
It is never easy to be wedged between two doctors in a medical debate.
I thank Irene Oldfather for bringing this debate to Parliament. As one of the conveners of the cross-party group in the Scottish Parliament on Alzheimer's, I would also like to take this opportunity to thank Irene for all the work that she has done on the issue, and for the commitment that she has shown. Given the amount of work that MSPs have, it is often difficult for us to attend meetings of cross-party groups, but they are a crucial part of our work and provide us with a great opportunity to work with service users and people who are experienced in understanding and providing services. Cross-party groups are a major part of our work that goes largely unnoticed outside Parliament, but the report is a success story for the cross-party group on Alzheimer's.
I would also like to thank Professor June Andrews, the Royal College of Psychiatrists and the many others who contributed to the report. As people live longer, the problem that we are debating today is likely to become greater. Any increase in investment for training and services in order to reduce hospital admissions—emergency or otherwise—and to provide people with the appropriate care and treatment for their condition is welcome.
I met Irene Oldfather in the black and white corridor about an hour ago, and I have never seen her so happy. She was jumping for joy because all the recommendations in the report have been accepted by the Government. I know that the Government has also agreed to write to all NHS boards, attaching guidance on implementation of the six recommendations. Although I am ecstatically happy about that, it means that the rest of my speech is irrelevant, because it was all about campaigning on those issues.
I felt uncomfortable about campaigning for A and E departments to diagnose dementia, but I appreciate that that is not quite what we are asking for. From what I have read, I think that it is possible for tools to be used in order to highlight problems, and I accept that that will happen.
As Ian McKee said, the best approach has to be the preventive approach, given that 40,000 people with dementia live in the community and use general hospital services, and that a further 70 per cent of those with dementia who present at A and E departments have not received a formal diagnosis. I should also say that I endorse the point that Ian McKee made about home carers.
Delighted as I am with the Government's response, there are two points in it that we need to monitor because they concern issues that are not entirely in the Government's control. Since the Scottish Parliament was set up in 1999, we have been calling for health and social services to work together. In many communities, that partnership is excellent. However, in its response, the Government says:
"Multiple programmes should already be in place in the community".
I would say not only that they "should … be in place" but that the Government needs to check to ensure that they are in place and working.
Another concern involves cultural change, which is dealt with in point 5 in the Government's response. I appreciate that such change takes time, but there is no doubt that it can take place.
Recommendation 4 in the cross-party group's report states that better partnership working between health and social services is crucial, and that there must be better integration of information technology systems and more specialist assessments in the community. I do not think that the NHS and local authorities make best use of the IT systems that are available to them. We should not allow anything to stand in our way in that regard, because effective use of IT leads to more integrated, better informed and better quality services.
I commend the excellent—often unnoticed—work that is done by all cross-party groups in the Parliament. I acknowledge the success of the report of the cross-party group on Alzheimer's. I think that the Government's announcement of its intention to implement the report's recommendations will encourage many other groups to produce similar reports.
I add my congratulations to Irene Oldfather for today's result. It is a testament to the hard work that she has put in, and to the hard work of others such as Dr Gillian McLean, Professor June Andrews and Jan Killeen of Alzheimer Scotland. I declare an interest as a psychiatrist who has connections as an honorary chair at the University of Stirling, having previously carried out some research on dementia at that university.
Other members have referred to the fact that there are some 60,000 sufferers of dementia, of whom two thirds are in the community. In 1980, I was part of a mental health planning group that produced the Timbury report, which was largely ignored. We estimated at that time that there were only about 20,000 people with the condition, which demonstrates how much it has increased. As the "Mirage of Health", as it has been described, changes—as heart disease begins to decline, as it has done for 15 years, and as we begin to tackle cancer more effectively—the next element of ill health that will be prominent is dementia, so it is right that we are debating the issue.
It is a challenging task, as Mary Scanlon said, to diagnose dementia in A and E, but if poorer levels of cognition and poor memory at least are not recognised in that setting, the people who work in that setting are doomed to achieve a great deal less than they otherwise might. Mary Scanlon said that 70 per cent of patients with dementia who present at A and E are not already diagnosed, which is true, but it is also estimated that about 25 per cent of A and E patients suffer from dementia. It is, therefore, important that the proper tools are put in place.
To begin with, we need formal guidelines, but I note that no such guidelines are mentioned in the report. We need to ensure that the triage tools that are used are more sensitive to dementia, and that cognitive function is assessed, rather than simply using the Glasgow coma scale for people with depressed consciousness. There is a need for the use of appropriate tools to achieve much fuller psychological assessments, such as the mini mental state examination, a memory impairment scale or other validated brief intervention tools that would allow diagnosis.
It is important that people in A and E are properly trained—the specialist nurses to which the report refers can play a part in that, along with places such as the Dementia Services Development Trust in Stirling. If people are aware and adequately trained, they will be much more able to deal with those issues.
Staff need to consider issues other than those that are usually straightforward. They need to consider things such as hydration and nutrition, because dementia patients are often not aware that they have not had a drink or a meal. Issues such as drug toxicity, to which Dr McKee referred, are also important, because they can occur more in people who are confused and are not taking their medication appropriately.
We have talked repeatedly in the chamber about violence towards staff, which is very unwelcome in any setting, but staff need to recognise and remember that aggression, for example, in some patients may be a presentation of pain. Other members have referred to the emergency care record, which needs to be flagged up as part of the quality and outcomes framework contract in general practice so that NHS 24 can try to ensure that patients are managed at home and not brought to hospital. If patients do go to hospital, NHS 24 can warn A and E that the person suffers from dementia. Also, hospital pharmacists—not only in A and E, but in the general hospital—need to have access to the emergency care record. I have asked parliamentary questions on that matter.
We can make progress, but it is important that this group of people, who are often neglected, achieve and receive the support that they need. Such people must never be boarded out—that is, they must not be transferred to another ward for the purpose of releasing a bed. Even moving a patient with dementia from one bed to another within a ward is not appropriate. Protocols and measures must be put in place.
I welcome the Government's response to the cross-party group's report, and I again congratulate those who were involved in its early production. I was glad to be present towards the end of its production; I hope that my comments were helpful.
I begin by thanking Irene Oldfather not only for securing this evening's debate but, more important, for her tireless and tenacious work in trying to help many thousands of our fellow citizens. I declare an interest: my father-in-law suffers from dementia. Such people are not alone when Irene Oldfather is in this chamber. I want to put my thanks to her on record.
I also thank others, even though—like me—they may not be so involved and may not attend so many meetings of the cross-party group on Alzheimer's. I am proud to be a member of that group. The work of Parliament is enhanced by the work of cross-party groups, which place experts from outside Parliament alongside MSPs of all parties to work together on issues that we consider to be important and urgent.
Few Scottish health issues can be more important than dementia. It is a growing problem, and demographics show clearly that the situation will get worse. The Government acknowledges that, which I welcome.
The cross-party group's report contains six recommendations, all of which have real merit, and behind the recommendations stands a good body of work. After the services that are provided by health boards in Scotland were considered, it became clear that no health board is doing enough for people with dementia.
This evening we have focused on accident and emergency services, but wider issues arise when we consider how the health service as a whole deals with people with dementia when they meet personnel whom they do not normally meet. Before he entered a care home, it was suggested to my father-in-law that he should have an operation on his eyes. The operation would have meant that he had to sit with his head held still in a particular position for three or four months. When it was pointed out to another member of staff that he was in his eighties, had dementia, and could not stay still for more than two minutes, it became clear that, in the health service, the left hand did not know what the right hand was doing. Later, the issue was addressed and resolved.
It is not only in accident and emergency units that issues arise. The system that allows such issues to be flagged up should be much more effective than it is at present.
When dealing with a patient with dementia, professionals must listen to families and carers, who will know much more about how their loved one is affected by this dreadful condition—for example, by mood swings. Richard Simpson is right to say that the effects can come out as aggression towards families and staff.
Accident and emergency services have to be improved. It is quite unacceptable that a person with dementia should have to sit in a waiting room for hours; it may even be impossible for them to do so. Staff training is required—because people with dementia have a greater chance of falling, it is likely that they will make up 25 per cent of the patients in an accident and emergency unit. Every member of staff should therefore have some form of dementia training.
We should not underestimate the importance of preventing as many falls as possible and we should do what we can to prevent hospital admissions in the first place. However, we all know that, no matter how much we care for a relative, and no matter how good a care package is put in place by social workers and local health professionals, such falls and such disorientation will always be highly likely, because of the nature of dementia.
It is important that the Government takes on board what we have said about dementia-trained nurses, but it is almost more important that training is embedded more generally for all staff in the health service, given the nature of the problem. We must also try to minimise the number of interactions that older people, particularly those with dementia, must go through. Our watchword at all times should be "dignity"—the dignity of the human condition. Dementia strips that from people, so we must build into the health service measures that give people their dignity at all times.
I thank Irene Oldfather for bringing this important debate to the Parliament. We have led the way in making dementia a national priority. I welcome the support and attention that the Scottish Parliament and, in particular, the cross-party group on Alzheimer's have given to dementia, and I look forward to continuing to work with the Parliament in future. Last year, when I met the Scottish Dementia Working Group—the only patient-led dementia group that we know of in the world—it showed its support for our commitment and focus, but it was clear that there is more work to do before we can be satisfied with dementia services in Scotland. I agree.
In the past year, we have taken several steps to establish dementia as a national priority in practice. We now have a national NHS target that requires all health boards to deliver by 2011 agreed improvements in the early diagnosis and management of patients with dementia. From the review visits at the end of last year, it is clear that boards are already getting to grips with that important agenda. The mental health collaborative, which supports local delivery of national NHS targets, published a toolkit at the end of last year that is designed to enable boards to analyse their dementia services from the perspective of those who use the service. The information from the analysis will be used to make progress with local service redesign to improve interventions, outcomes and the patient experience of the service.
Health boards are working with general practitioners to improve their knowledge and understanding of dementia with the aim of increasing the rate of early detection and referral to specialist services. Diagnosis means more than going on a register; it triggers regular physical health checks for those with dementia, as well as formal assessment of the needs of those who care for them. To build on the work to improve diagnosis, we have commissioned Alzheimer Scotland and the dementia services development centre at the University of Stirling to carry out work in Lothian, East Renfrewshire and Renfrewshire, and Shetland to develop better structured intervention, support and information services following first diagnosis. The work is intended to develop our understanding of how we can best offer those services so that they meet patients' and carers' needs in an understanding and sensitive manner.
The project has developed from what we have already learned from the work of the dementia services development centre in Forth Valley NHS Board. That work provided a focus for service development, together with information, education, and tools and techniques to implement change, with the aim of improving the overall experience and outcomes of care for people with dementia. We published the outcomes of that work last year, and boards are now using that information in the redesign and development of services.
NHS Health Scotland is offering post-diagnostic support through the publication "Coping with Dementia—A practical handbook for carers", which is widely available in Scotland, and through the publications "Worried about your memory?" and "Facing Dementia: how to live well with your diagnosis", which were recently updated by NHS Health Scotland working with Alzheimer Scotland and the Scottish Dementia Working Group.
In 2008 we undertook research into public attitudes to and understanding of dementia, and we will shortly launch a pilot public awareness campaign in Tayside to increase the number of people with dementia coming forward for diagnosis. We will evaluate the outcome of the campaign and use the learning from that to inform possible future national campaign work.
Irene Oldfather mentioned memory clinics. They are one way in which dementia can be identified and responded to, and recent research has identified that they are a common component of old-age psychiatry services in Scotland.
We are taking forward work on awareness raising, early diagnosis and information for people with dementia and their carers. The development work on the integrated care pathways, which will be accredited from later this year, also brings a focus to end-of-life care, social support and quality of care. I am glad that those developing the English strategy have been able to learn from the Scottish experience.
We, too, are happy to learn, and I welcome the report from the cross-party group on Alzheimer's. It has highlighted the needs of people in A and E who have dementia and identified areas in which clear improvement is possible, and I am pleased to be here to respond to the debate on it, particularly given that my response can be positive.
It is important that we can identify properly those who come into A and E who may have dementia and that we can track them through their time in the unit. In that way, we can ensure that they receive the sensitive care that they need. Staff in A and E need to know how to care for people with dementia, and it is important that cultures and behaviours are appropriate for this patient group. I agree that the more that we can do to prevent those with dementia ending up in A and E the better, but if people end up in A and E the way in which they are treated is crucial. It is for that reason that I have written to all NHS board chairs and chief executives to indicate my support for the report and provide guidance on how boards can implement its recommendations. The guidance that was provided was drawn up with the support of the dementia services development centre.
I turn to the two points that Irene Oldfather raised. On the first point, I assure her that we will look at how to ensure joined-up working across health and social care as implementation takes place. Although the report's recommendations focus on A and E, they are relevant to other care settings, so it is important for us to do that.
In my reading and preparing for the debate, an issue that MSPs have raised over the years was once again brought to my attention. I refer to the problems of malnutrition, lack of regular and nutritional meals, and dehydration. Is the minister looking at that issue?
Quite a lot of work has been done on the issue, particularly considering the new role of the senior charge nurse. We want to ensure that those in that leadership role on the ward pay much more attention to the nutritional needs of people in their care. A lot of work is also going on in care homes. I can write to the member with more details on that: patients' medical needs are important but so too are their personal care needs, including nutrition.
Irene Oldfather's second point was on specialist nurses. The role of dementia specialist nurses is part of the solution in caring for people with dementia who are in hospital, but we must not forget that the main thrust of the report's recommendations was that all staff should receive training in dementia. We must be cautious as we do not want to end up giving the impression that all the responsibility comes down to one person. All the recommendations were important, but the key recommendation was to ensure that all staff have a basic awareness of and training in dementia. We will look in more detail at how to take that forward.
I have written to the convener of the cross-party group on Alzheimer's to set out the steps that I have taken, and I am happy to join the Parliament in giving my support to the motion. We are clear about the challenges that we face in offering high-quality and sensitive care to people with dementia, and we will not shirk the need to take action. I assure members that I have heard the issues that they have raised and I will reflect on them in the development of our further plans. I am happy to continue to work with the cross-party group on Alzheimer's as we take forward that work.
Meeting closed at 17:39.